Livingston and Burchell found a 3-fold increase in the number of Medicare patients seeking surgery, and a 14-mile increase in the median distance traveled, following the Medicare national coverage determination in 2006. They conclude that the Medicare COE requirement decreases access to bariatric surgery, without any resulting patient benefit.

Health care accessibility is determined by geographical, financial, cultural, and informational factors. While Livingston and Burchell demonstrate increased median distance traveled, they do not address the time, convenience, or cost of access to care. Financial barriers should not be underestimated, with many bariatric programs forced to limit access to Medicare patients to maintain financial viability. Our own center (Oregon Health & Science University hospital) has restricted access to Medicare patients for this reason. It appears some patients traveled a long distance to Dallas despite the presence of a COE closer to home. The results presented show an increased use of bariatric surgery at UTSW, without demonstrating decreased access overall.